Crown of Confidence Wig Assistance Program / Financial Assistance & Eligibility Application

Please include yourself, spouse/partner, dependent children, and other individuals financially supported by the household.

This is important because Purdy will perform its own benefit verification. Authorization to Verify Insurance Benefits. I authorize Purdy Medical Wigs & DME Suppliers LLC and its authorized representatives to contact my health insurance company for the purpose of verifying benefits and coverage related to a cranial prosthesis/medical wig. I understand that verification of benefits is not a guarantee of coverage or payment. Final coverage and reimbursement decisions are made by my health insurance plan according to the terms and conditions of my individual policy. I authorize the release and exchange of information reasonably necessary to complete this benefit verification.

Please provide ONE of the following: - Current Medicaid eligibility/card - Recent pay stub - SSI/SSDI award letter - SNAP/TANF eligibility documentation - Unemployment benefit statement - Recent benefits statement - Most recent tax return, if other documentation is unavailable - Other documentation demonstrating financial hardship

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that submitting this application does not guarantee approval for the Crown of Confidence Wig Assistance Program or guarantee that I will receive a cranial prosthesis. I understand that eligibility and the amount of assistance provided are determined based on financial need, medical need, insurance benefits, available funding, donations, sponsorships, program resources, and other applicable eligibility criteria. I understand that additional documentation may be requested to complete the review of my application. If I am approved but assistance is not immediately available, I understand that I may be placed on the Crown of Confidence Program waiting list. Applicants are generally assisted based on the date their completed application is received; however, medical urgency, financial hardship, available resources, and other exceptional circumstances may also be considered. I understand that approval for program assistance does not constitute health insurance coverage and that Purdy Medical Wigs and ANU Community Development Corporation cannot guarantee payment or reimbursement by my health insurance plan. By signing below, I certify that I have read, understand, and agree to the statements above.